Professional Documents
Culture Documents
2d 1072
54 USLW 2094
Following his injury on March 19, 1979, Myers incurred $3,906.89 in medical
expenses. SATI paid Myers the full coverage of $5,000 under its policy, which
authorizes indemnification for "non-medical expenses and pain and suffering."*
SAMBA, however, paid Myers only the $50.00 deductible under the SATI
policy, refusing the remainder of Myers' medical expenses claim on the ground
that the SATI policy represented double coverage. The double coverage
exclusion of the SAMBA policy is applicable when "a person is eligible for
benefits under any other kind of group health coverage...." * It requires, in such
cases, that benefits be reduced to an amount which will not exceed all
reasonable and customary expenses "when added to the benefits available from
all plans for the same covered expenses." The district court determined that the
SAMBA and SATI plans "plainly provide coverage for two different types of
loss," and ruled that Myers was entitled to recover $3,856.89 under the
We agree. While the SAMBA and SATI plans are both group policies, the
SATI plan is not health insurance, but an accident indemnification plan
covering non-medical losses, and so falls outside the double coverage
provision. A health benefits plan, as defined by 5 U.S.C. Sec. 8901(6), is a
group insurance policy provided "for the purpose of providing, paying for, or
reimbursing expenses for health services." It is obvious from the face of the
SATI policy that expenses for health services are not being reimbursed, but
only non-medical expenses and pain and suffering, as expressly stated. Medical
expenses and reimbursement for non-medical pain and suffering cannot be
equated.
The government relies on a 1979 OPM decision that found the SATI policy
provision in issue to constitute double coverage with the SAMBA plan, because
medical expenses must be incurred as a precondition to payment by SATI.
Under the SATI policy, the amount of indemnity is "equal to the expense
incurred for the medical and dental treatment of the bodily injury." We are, of
course, required to defer to an administrative agency's interpretation of its own
regulations unless "plainly erroneous or inconsistent with the regulation."
United States v. Larionoff, 431 U.S. 864, 872, 97 S.Ct. 2150, 2155, 53 L.Ed.2d
48 (1977), quoting Bowles v. Seminole Rock Co., 325 U.S. 410, 414, 65 S.Ct.
1215, 1217, 89 L.Ed. 1700 (1945); Allen v. Bergland, 661 F.2d 1001, 1004
(4th Cir.1981). Here, however, the OPM interpretation is not a reasonable one,
and must be regarded as inconsistent with the double coverage provision. OPM
was not entitled to disregard the express non-medical nature of the SATI
coverage merely because benefits were calculated with reference to medical
expenses. Pain and suffering, being subjective, must necessarily be assessed by
an insurer according to some objective criterion. There was nothing
inappropriate in SATI's selection of medical expenses as a means to quantify
such loss, rather than paying some arbitrary sum.
We also concur in the district court's denial of attorney's fees claimed by Myers
under South Carolina law. It is unnecessary to decide whether SAMBA's
refusal to pay was "without reasonable cause or in bad faith," as required by the
state statute in issue, S.C.Code Ann. Sec. 38-9-320(1) (1985), for we conclude
that state law is preempted where a federal employees' insurance policy and the
regulations pertaining thereto are concerned. 5 U.S.C. Sec. 8902(m)(1) (1982)
provides:
The provisions of any contract under this chapter which relate to the nature or
extent of coverage or benefits (including payments with respect to benefits)
shall supersede and preempt any state or local law, or any regulation issued
thereunder, which relates to health insurance or plans to the extent that such law
or regulation is inconsistent with such contractual provisions.
8
Nowhere does the SAMBA policy or the relevant federal law authorize a
plaintiff to recover attorney's fees in an action brought under 5 U.S.C. Sec.
8912, and a state law which purports to allow recovery of additional benefits
not contemplated by a federal insurance contract must be deemed inconsistent.
Accordingly, federal law precludes any award of attorney's fees here.
For the reasons stated, both the district court's judgment in plaintiff's favor for
$3,856.89 in insured medical expenses and the denial of attorney's fees are
10
AFFIRMED.
CLARKE, District Judge, dissenting:
11
I respectfully dissent. I would reverse the district court's determination that the
plaintiff's claim for benefits under the SAMBA Health Benefits plan did not
fall within the "Double Coverage" provision promulgated by the Office of
Personnel Management (OPM). In my view, the plaintiff's claim did fall within
the double coverage provision of the SAMBA policy.
12
The Federal Employees Health Benefits Act (the Act), 5 U.S.C. Sec. 8901, et
seq., was enacted to provide health insurance protection for federal employees.
It is a comprehensive statutory scheme, regulating all aspects of federal
employee health benefit plans. The Office of Personnel Management (OPM) is
charged with administering the Act, 5 U.S.C. Sec. 8902. Because the SAMBA
plan is a health benefits plan under the Act, it is subject to "such maximums,
limitations and other definitions of benefits as the OPM considers necessary or
desirable." 5 U.S.C. Sec. 8902(d).
13
Pursuant to its statutory authority in 5 U.S.C. Sec. 8913, the OPM promulgated
in January 1979 the limitations provision known as a "Double Coverage"
provision to be applied in all health benefits plans sanctioned under the Act.
The double coverage provision states in pertinent part that:
DOUBLE COVERAGE
14 Double Coverage limitation is intended to prevent payment of benefits which
The
exceed expenses. It applies when a person is eligible for benefits under any other
kind of group health coverage, Medicare, or "no fault" automobile insurance. When
Double Coverage exists, this Plan will pay either its benefits in full or a reduced
amount which, when added to the benefits available from all plans for the same
covered expenses, will not exceed 100 percent of reasonable and customary
expenses; but in no case will this Plan pay an amount which is more than what
would have been paid in the absence of other insurance.
15
According to a letter from SAMBA to its membership dated June 25, 1979,
SAMBA officials became concerned about those of its enrollees who were also
enrolled in another group accident plan available to FBI agents. The SAMBA
officials believed that the other plan provided payments which would be
considered double coverage under the SAMBA plan, so they formally
requested an OPM ruling on that issue. The specific SATI provision which was
believed to constitute double coverage read:
16
17
After scrutinizing the SATI policy terms according to the National Association
of Insurance Commissioners' Guidelines for Coordination of Benefits (Double
Coverage), the OPM ruled that the SATI policy accident indemnification
provision constituted double coverage under the January 1979 double coverage
provision.
18
20
21 believe it constitutes double coverage for the following reasons: ... To receive
[We]
benefits for coverage provided for temporary non-permanent accident disability, an
insured is required to incur expenses for medical or dental treatment, services or
supplies.
22
Id.
23
The district court, as well as the majority of this court, disagrees with the
OPM's interpretation of the SATI plan. They give literal effect to the words of
the SATI plan which state that it provides coverage for non-medical expenses
and pain and suffering.
24
25
I would uphold the OPM's position, not because of Allen, supra, but because it
reached a legally sound conclusion.
26
The district court found that the SATI policy did not constitute double
coverage. It based this finding on the words of the SATI policy which state that
its payments are for non-medical expenses and pain and suffering. The Court
wrote:
27 and suffering is difficult to quantify; and the SATI policy merely uses the
Pain
amount of medical expenses as a starting point for the calculation.
28
29
The SATI policy, however, did more than use the amount of medical expenses
Although the majority was satisfied that SATI merely selected medical
expenses as an objective criterion with which it could quantify a policy-holder's
pain and suffering, nothing in the record indicates that medical expenses are in
fact an objective measure of pain and suffering. Medical expenses very often
have no correlation to non-medical losses such as time missed from work,
dismemberment, permanent disability, or percentage loss of use of a body part.
It is a matter of common experience that the most excruciating headache can
result in time missed from work, impaired ability, and severe pain but cost the
suffering individual no medical expenses at all, or at most the cost of a bottle of
aspirin tablets. In contrast, many disorders require continued treatment with
many visits to the doctor but involve little or no discomfort for the patient.
31
If SATI truly was concerned about reimbursing only non-medical expenses and
pain and suffering, I am of the opinion that it would have considered more
indicia of loss than mere medical expenses. I would hold, as the OPM held, that
the SATI plan was intended to cover and did cover medical expenses
regardless of the fact that it described the plan as a "non-medical expense"
policy.
32
At oral argument on this matter, some significance was attached to the fact that
SATI paid the plaintiff-appellee its policy limit of $5,000 even though his
medical expenses were $3,906.89. The Court was urged to view this as
evidence that SATI was paying for different expenses than those medical
expenses which SAMBA had agreed to cover.
33
The first page of the SATI policy lists the various coverages available in the
policy. They are: (1) accidental death and dismemberment insurance; (2)
accidental indemnification for non-medical expenses; (3) hospital disability
income protection and (4) long term disability income protection.
34
The record reveals that Myers was enrolled in more than one SATI plan. In
addition to the accident indemnification plan that is at issue in this case, Myers
was also enrolled in a separate Hospital Disability Income Protection plan as
well as a Long Term Disability Income Protection plan. Although the district
court stated that SATI paid the plaintiff $5,000 under the accident
indemnification provision, the record reveals otherwise. SATI paid Myers only
$3,820.25 based on medical expenses incurred from March 19, 1979 through
June 16, 1979 under its accident indemnification plan. It paid him $1,029.04
based on loss-of-income during his three hospital stays under its Hospital
Disability Income Protection plan.1 Thus, the $5,000 that SATI paid Myers
must be viewed as the total of all payments for each of the various SATI
coverages with which Myers filed claims. Although not all such plans overlap
with the SAMBA plan, the accident indemnification plan does overlap with
SAMBA.
35
36
The same logic must apply to an analysis of whether the SATI and SAMBA
plans both provided coverage for the same loss. The simple fact that Myers was
insured under several separate SATI plan coverages can have no bearing in a
determination of whether the SATI accident indemnification plan duplicated
benefits payable under the SAMBA plan. Although the total payment figure of
$5,000 paid by SATI may not be entirely duplicative of benefits available
under SAMBA's plan, the $3,820 that SATI paid based on Myers' medical
expenses was duplicative and constituted double coverage. I think that the
OPM was entirely correct in ruling that the Double Coverage provision in the
SAMBA policy prevented SAMBA from paying any medical expenses that
were covered under SATI's policy.
37
gives its policy coverages, but it should examine the terms of the policy to see
what it really covers. The district court should have done that in this case and
ruled that the SATI "non-medical" accident indemnification plan, with its
requirement that payments equal medical expenses, did come within the double
coverage limitation of the SAMBA policy.
38
I would reverse the District Court and enter final judgment for appellant
SAMBA on the principle issue and would affirm the district court on the denial
of Myers' attorney's fees.
SAMBA's General Manager admitted that SATI had paid $5,000, and the
district court so found. The government contends that Myers received only
$3,820.25 under the SATI plan as "Accident Indemnification for Non-Medical
Expense," and that the remaining payment bringing Myers up to the total policy
coverage was under the separate "Hospital Disability Income Protection"
coverage of the SATI policy. We need not determine the precise source of the
SATI payments, as it does not affect our analysis